In October 1987, Sally Hutchings threw two overripe tomatoes at the then State President P W Botha at a university reception in Pretoria1 in protest against the increasing encroachment of the National Party government on university autonomy. The projectiles missed him, landing at his feet. Within hours Hutchings, a statistics lecturer at UNISA, was deported to her native England with her 18-month-old baby. The then acting Home Affairs Minister, F W de Klerk, considered her action 'in a very serious light' as 'should the object have contained explosives, the lives of the State President and other persons could have been in jeopardy'.1,2 At the time, the incident was treated as a ludicrous instance of repressive over-reaction by a regime seeking to maintain unjust policies in the face of near-universal criticism.

We re-ran history recently. Dr Mark Blaylock is the chief medical officer at Manguzi Hospital in the rural Umkhanyekude district of KwaZulu-Natal. He was suspended for a month without pay after he placed a framed photograph of the political head of health in KwaZulu-Natal province, Ms Peggy Nkonyeni, inside a dustbin in the hospital. He did this in frustration after a meeting in which she openly criticised rural doctors for not caring about patients, but only about profits, and warning that antiretroviral therapy was toxic. This happened after the suspension of Dr Colin Pfaff, who supplied dual therapy to pregnant women with HIV/ AIDS at a time when this was not yet the official protocol of the Department of Health.

Pfaff's actions essentially incurred no cost to the Department of Health and occurred in the face of further delays in the release of dual therapy PMTCT guidelines by the Department of Health. Pfaff's actions probably saved a large number of infant lives, a fact not acknowledged by the Department. Dual therapy is internationally recognised as being more efficacious than monotherapy in the prevention of mother-to-child transmission of HIV, and is implemented in several countries that are poorer than South Africa.3 Pfaff's suspension was later withdrawn.

Both the tomato and binning the photo were symbolic - the tomatoes barely dirtied Botha's shoes, while the Nkonyeni photo was undamaged. While some might regard these actions as 'disrespectful', 'inappropriate' or 'rash' (the Health Minister, perhaps predictably, invoked 'anarchy' in describing Blaylock's conduct4), they were not senseless. And, others may even argue, not necessarily excessive. Yet excessive action was taken against both protestors, while the HIV programme, lacking cohesive and scientific leadership at a national and provincial level for years, continues to be an embarrassment to many committed health care workers.

While these cases may spark a much-needed debate on the limits of peaceful protest in democratic South Africa, the Blaylock incident highlights the urgent need to focus on health worker morale and credible leadership in rural health facilities. Blaylock's suspension - also now lifted after much civil society protest - will further limit the number of local doctors in a hospital that attends to more than a 100 000 people in a province with the highest HIV prevalence in the country.

The incident also sadly points towards the fact that AIDS denialism is still alive and well in certain government circles. Nkonyeni's comments casting doubt on the success of antiretroviral therapy are in the classic mode of AIDS dissidents who invoke spurious doubts about toxicity to engender doubts among those in need of the drugs. These issues require critical attention for the much-lauded National Strategic Plan to be a success and in order to halt the medical brain drain in South Africa. Nkonyeni should instruct her staff to move on antiretroviral access, PMTCT coverage and the TB programme - all hopelessly underperforming programmes in her province - with the same urgency and dedication that the defence of her photograph triggered.

Ironically, before she threw the tomatoes Hutchings had been planning to relocate to England, and received a free trip to London at South African taxpayer's expense. During his suspension period, Blaylock would be able to earn substantially more in private practice than working in the public sector. Paradoxically, the excessive action taken against both could be viewed to have financially benefited both individuals. Yet in both cases South Africa lost out on much-needed skills, expertise and experience. Self-absorbed and underperforming political authorities across the decades seem unable to grasp this fact.

3. Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women and their Children. Guidance on Global Scale-up of the Prevention of Mother to Child Transmission of HIV: Towards Universal Access for Women, Infants and Young Children and Eliminating HIV and AIDS among Children. Geneva: WHO, 2007. http://whqlibdoc.who.int/publications/2007/9789241596015_eng.pdf (accessed 9 June 2008). [ Links ]